Child Abuse
There are approximately 1,200 deaths from child abuse or nonaccidental trauma annually. Approximately half of these deaths happen in the first year of life. About half of the children who died were known to their local child protective service agencies.
The most common injuries were soft tissue followed by fractures. It is estimated that one out of four fractures in children under 1 year of age are from abuse. The most common fracture for children with just one fracture is the femur, followed by the humerus, followed by the skull. Posterior rib fractures are found in up to 30% of abused children, with the majority found in those under the age of 2 years.Initial action depends on whether the suspicion is great enough to warrant making a report to Child Protective Services (CPS) (370). It is essential to obtain a detailed history, including the mechanism of injury, and to look for inconsistencies. Knowledge of child development is essential. Suspicion is increased if the injuries are inconsistent with the child's developmental level or mechanism of injury, blamed on the victim's siblings, or not witnessed. Children, for example, generally cannot roll over until the age of 4 months. Most children that fall off a piece of furniture have a fracture risk of less than 2 percent. Therefore, a history of a 3-month-old rolling off a piece of furniture and sustaining a severe injury should raise suspicion of child abuse. Multiple injuries in various stages of healing should increase suspicion.
With suspected child abuse, physical exam includes an ophthalmological examination for retinal hemorrhages as well as a head-to-toe examination that also looks for skin bruising, swelling or deformity of extremities, malnourishment, and poor hygiene. Photos are useful for clinical documentation of any abnormalities and frequently document skin marks, bruises, welts, or burns.
An AP and lateral films are necessary for any extremity that is tender, has swelling, or has limited range. A radionucleotide study can be an added help to the skeletal survey. Remember that there are no pathognomonic fracture patterns, but high suspicion fractures include posterior rib fractures; metaphyseal corner fractures; sternum, scapula, or spinous process fractures; bilateral acute long-bone fractures; complex skull fractures; fingers in nonambulatory children; and multiple fractures in various stages of healing. The most common type of fractures involved with child abuse are transverse, followed by spiral fractures, followed by avulsion fractures, followed by oblique fractures. Those fractures with low specificity include clavicle fractures, simple skull fractures, and isolated long-bone fractures (371). When child abuse is suspected, the physician is legally obligated to file a report with the appropriate child protection agency. Adequate supportive measures and counseling should be in place before returning any abused child to the home. When in doubt, temporary foster placement should be seriously considered.